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Impact of PCI vs. CABG on outcomes varies by acuity of presentation in diabetes
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The mode of revascularization and acuity of presentation appear to affect short-term outcomes among patients with diabetes and multivessel disease, leading researchers for a new study to call for further investigation into the optimal revascularization strategy for patients with diabetes and ACS.
Krishnan Ramanathan, MB, ChB, clinical assistant professor at University of British Columbia, Vancouver, and colleagues analyzed real-world data from a population-based database from British Columbia that included 4,661 patients with diabetes and multivessel disease who underwent CABG or PCI with first- or second-generation stents. Of those, 2,947 patients had ACS. PCI was the preferred revascularization strategy in 60% of the overall cohort.
At 30 days, MACCE, defined as a composite of all-cause death, nonfatal MI and nonfatal stroke, was lower among patients with ACS who underwent CABG (OR = 0.49; 95% CI, 0.34-0.71). The researchers also compared 30-day MACCE among 1,802 patients with stable ischemic heart disease, as “previous studies of CABG vs. PCI in diabetes mellitus patients with multivessel CAD consisted mostly of patients with stable ischemic heart disease.” In this group, MACCE at 30 days was not affected by revascularization strategy (OR = 1.46; 95% CI, 0.71-3.01).
From 31 days to 5 years (median, 3.3 years), MACCE did not differ between the CABG or PCI strategy based on acuity of presentation. The researchers reported an HR of 0.67 (95% CI, 0.55-0.81) among patients with ACS and an HR of 0.55 (95% CI, 0.4-0.74) among patients with stable ischemic heart disease.
“During long-term follow-up, all individual components of MACCE were lower in patients undergoing CABG, notably a statistically significant 52% relative risk reduction in all-cause mortality,” Ramanathan and colleagues wrote.
Sensitivity analyses corroborated the findings.
The researchers noted substantial differences in clinical and angiographic characteristics at baseline, with more unfavorable clinical characteristics present in the PCI group.
“These important differences, combined with higher rates of ACS patients in the PCI group, is entirely consistent with the current practice of generally higher-acuity patients and those declined for CABG undergoing high-risk PCI,” Ramanathan and colleagues wrote.
Cardiology Today Editorial Board Member Sripal Bangalore, MD, MHA, and Cardiology Today’s Intervention Chief Medical Editor Deepak L. Bhatt, MD, MPH, discussed the findings in a related editorial. They noted that the findings in this study are in contrast with previously published studies such as BEST, EXCEL and NOBLE, as well as findings from New York state registries, which showed favorable outcomes with PCI vs. CABG in the short term, and similar outcomes in the longer term.
“The short-term lower risk with CABG when compared with PCI seen in the British Columbia registry is possibly due to residual confounding,” wrote Bangalore, associate professor of medicine, director of research of the cardiac catheterization laboratory and director of the Cardiovascular Outcomes Group in the Cardiovascular Clinical Research Center at NYU Langone Health, and Bhatt, executive director of interventional cardiovascular programs at Brigham and Women’s Hospital Heart & Vascular Center and professor of medicine at Harvard Medical School. “Although the superiority of CABG over PCI over short-term follow-up in the ACS cohort is difficult to explain, it is possible that inability to identify the true culprit lesion in diabetic non-ST segment elevation myocardial infarction patients undergoing PCI results in less protection against recurrent ischemic events than does complete revascularization with CABG.”
Nevertheless, like the researchers, Bangalore and Bhatt also called for a randomized trial to test long-term outcomes of PCI vs. CABG in this patient population.
“The relative merits of CABG and PCI have been debated since the days of the BARI trial and will continue to be debated in individual patients for the foreseeable future,” Bangalore and Bhatt wrote.
Disclosures: Ramanathan reports no relevant financial disclosures. Bangalore and Bhatt report ties with numerous pharmaceutical and device companies. Please see the editorial for all their relevant financial disclosures.
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